heme onc Flashcards
1
Q
*What is the difference between Mean Corpuscular Hemoglobin and Mean Corpuscular Hemoglobin Concentration?
Normals for each?
A
MCH: avg WEIGHT (amount) of hg in one erythrocyte
- normal: 26 - 34
MCHC: avg CONCENTRATION of hgb, ie, the % proportion of an RBC occupied by hgb MORE ACCURATE
- normal: 32 - 36
2
Q
What is the percentage of a volume of whole blood that is erythrocytes?
A
hematocrit
3
Q
hematocrit normals
A
M 40 - 54%
F 37 - 47%
4
Q
What is Mean Corpuscular Volume? Normals?
A
avg vol & size of individual erythrocytes
MCV value 80-100
5
Q
Mean Corpuscular Hemoglobin Concentrations (MCHC)
A
average Hgb concentration
MCHC normal value 32-36%
6
Q
*Differentials for LOW MCV
A
iron deficiency anemia
thalassemia
7
Q
*Differentials for HIGH MCV
A
the megaloblastic anemias: B12 & folate deficiency
alcoholism, liver failure, drug effects
8
Q
*Differentials for NORMOCYTIC MCV
A
anemia of chronic disease sickle cell anemia renal failure blood loss hemolysis
9
Q
microcytic hypochromic anemias
A
iron deficiency
thalassemia
10
Q
macrocytic normochromic anemias
A
B12 (pernicious anemia)
folate deficiency anemia
11
Q
normocytic normochromic anemias
A
anemia of chronic disease
sickle cell anemia
blood loss
12
Q
What is iron deficiency anemia?
A
microcytic hypochromic anemia d/t overall decreased iron intake; less iron available for RBC formation
most common anemia
13
Q
iron deficiency anemia: s/s x9
A
SLOW onset; symptoms really kick in when hct drops below 30
** pica **
dyspnea, mild exertional fatigue
palpitations, tachycardia, postural hypotension
weakness, pallor, HA
14
Q
iron deficiency anemia: hallmark diagnostics x4
A
Low MCV & MCHC **
Low ferritin ** (stores)
High TIBC ** (capacity for more iron)
15
Q
iron deficiency anemia: management
A
Ferrous Sulfate 300-325 mg PO 1-2 hours after meals
+ foods high in iron
16
Q
Ferrous sulfate: indication and considerations x4
A
treatment for iron deficiency anemia
- take 1-2 hours after meals
- vitamin C increases absorption
- do not take with antacids (interfere with absorption)
- GI effects: n/v/d/ cramps
17
Q
What is ferritin?
A
iron stores
18
Q
What anemia is characterized by low ferritin and high TIBC?
A
iron deficiency anemia
19
Q
What is thalassemia?
A
- microcytic hypochromic anemia
genetic disease = abn hgb production
20
Q
thalassemia: s/s
A
unremarkable unless severe
21
Q
thalassemia: diagnostics
A
Low MCV & MCHC **
Normal ferritin & TIBC **
Decreased hgb & alpha or beta chains in hgb
22
Q
thalassemia: mgmt
A
none if moderate disease
if severe: RBC transfusion, splenectomy
NO IRON; IRON OVERLOAD RESULTS
23
Q
What is contraindicated in the management of Thalassemia?
A
iron - the body will be overloaded with iron because it can’t use it
24
Q
What is folic acid deficiency anemia?
A
macrocytic normochromic; anemia resulting from lack of folic acid, duh
** d/t either malabsorption or decreased intake **
folic acid is needed for RBC production
25
folic acid deficiency anemia: s/s
glossitis **
```
the standard other anemia s/s:
fatigue
pallor
palpitations
weakness
headache
```
26
folic acid deficiency anemia: diagnostics
High MCV (100+)
Normal MCHC (32-36%)
Low serum folate
Decreased HCT & RBCs
27
folic acid deficiency anemia: mgmt
Folate 1 mg PO QD
| + foods high in folic acid: naners, PB, fish, leafy greens, iron-fortified shits
28
What's an easy way you can differentiate between folic acid deficiency and pernicious anemia?
pernicious has neuro symptoms, folic acid deficiency does not
29
Which anemia is most important to ask alcoholic patients about?
folic acid deficiency: because of poor PO intake
30
What is pernicious anemia?
macrocytic normochromic, aka B12 deficiency anemia
buuuuuuuut really it isn't d/t lack of B12, it's d/t a deficiency of INTRINSIC FACTOR that results in MALABSORPTION of B12
31
pernicious anemia: s/s
NEUROLOGICAL SX EXPLOSION: parasthesis, loss of vibratory sense and fine motor control, + romberg and babinski
oh yeah, and glossitis** then all the typical anemia stuff
32
Your patient has a beefy ol' red tongue. "Oh shit," you say to yourself, "It might be..." ???
folic acid or pernicious anemia
33
pernicious anemia: diagnostics
↑ MCV
Normal MCHC
↓ serum B12 (less than 0.1)
↓ H&H + RBCs
anti-intrinsic factor (IF) and antiparietal cell ab test affirms deficiency
34
pernicious anemia: mgmt
cyanocobalamin (B12) 100 mcg IM QD x 1 wk
| maintenance: continuous life long monthly injections. that sucks
35
What is the dose and route of B12 indicated for B12 Deficiency Anemia?
B12 100 mcg IM x 1 week
| B12 100 mcg IM x 1 month for life
36
What the boop is anemia of chronic disease?
normocytic normochromic anemia in which the life span of erythrocytes is decreased
second most common cause of anemia, #1 in them ol' folks
37
anemia of chronic disease: causes
the etiology is unclear, but it is associated with
chronic inflammation
infection
renal failure
malignancy
38
Renal failure is associated with what -cytic/-chromic of anemia?
normocytic normochromic
39
anemia of chronic disease: diagnostics
Normal MCV & MCHC
↓ iron & TIBC
↑ ferritin
40
anemia of chronic disease: mgmt x3
TREAT UNDERLYING CAUSE
Nutritional support
Epoetin alfa (Epogen) - super third line option
IRON IS A NO NO - the body is already carrying tons
41
What is the most common type of anemia in the elderly?
anemia of chronic disease
42
Which two anemias is iron contraindicated in management plan?
thalassemia - body can't do shit with it
| anemia of chronic disease - the body already got too mucha dat shit
43
sickle cell anemia: pathophys
genetically transmitted disease → hemolytic and sickle shaped RBCs
acute exacerbations: RBC sickle & clump & occlude blood vessels (hyperviscosity)
→ cellular hypoxia → tissue ischemia & acidosis
murky blood + ischemia = pain pain pain
44
sickle cell anemia: precipitating factors
```
dehydration **
emotional or physical stress **
infection
blood loss
surgery
high altitudes
acidosis
```
45
What makes sickle cell crises so damn painful?
tissue ischemia & blood hyperviscosity
46
sickle cell crisis: s/s
sudden, severe pain: back, chest, extremities, aching joints** d/t blocked circulation
47
sickle cell anemia: mgmt
IVF first
analgesia: IV morphine & hydromorphone (Dilaudid)
O2
48
Your patient is having a sickle cell crisis - what is your priority intervention?
IVF to increase production of RBC
49
What anemia is characterized by:
↓ iron
↓ TIBC
↑ ferritin
anemia of chronic disease
50
What is leukemia?
Neoplasms arising from hematopoietic cells in the bone marrow.
51
Acute Myelogenous Leukemia (AML)
Leukemia: neoplasms arising from hematopoietic cells in the bone marrow.
80% of acute leukemias in adults
52
Chromic Myelogenous Leukemia (CML) hallmark sign
philadelphia chromosome in leukemic cells
53
Acute Lymphocutic Leukemia (ALL): hallmark lab **
pancytopenia with circulating blasts
54
Chronic Lymphocytic Leukemia (CLL)
most common leukemia in ADULTS
| lymphocytosis is disease hallmark
55
Pancytopenia with circulating blasts is the hallmark of what?
acute lymphocytic leukemia (ALL)
56
Philadelphia chromosome is associated with which kind of leukemia?
Chronic myelogenous leukemia (CML)
57
leukemia presentation
can be asymptomatic!
generalized lymphadenopathy
acute weight loss
fatigue, weakness, anorexia
58
leukemia diagnostics x3
definitive diagnosis: bone marrow aspiration
peripheral blood smear
bone marrow aspiration
59
What can you order to distinguish acute from chronic leukemia?
peripheral blood smear
60
leukemia: mgmt
chemotherapy
bone marrow transplantation
supportive care
RADIATION IS NOT A PRIMARY STRATEGY
61
What is lymphoma?
a lymphocytic malignancy - lymphocytes are a kind of leukocyte
- examples include NK and B cells
62
Describe Non-Hodgkin's Lymphoma
most common neoplasm in 20-40 yo
often presents with lymphadenopathy, spread is less predictable than Hodgkin's
advanced disease is usually apparent
63
Describe Hodgkin's Lymphoma
more common in males; avg age 32
usually presents with cervical adenopathy + a predictable spread
hallmark: Reed Sternberg cells
64
Which cancer often presents as cervical adenopathy with a predictable spread?
Hodgkin's lymphoma
65
How do you diagnose a lymphoma?
biopsy enlarged lymph nodes and staeg
66
lymphoma: general mgmt
radiation
chemo
bone marrow tx
67
Reed Sternberg cells are a hallmark sign of what type of cancer?
Hodgkin's lymphoma
68
What is idiopathic thrombocytic purpura?
thrombocytopenia (platelet deficiency) caused by autoimmune destruction of platelets
sometimes thrombopoiesis can be suppressed
usually a chronic condition, can be asymptomatic for long intervals
69
ITP: s/s
↑ bleeding & bruising
low platelet count
idiopathic thrombocytic purpura
70
Where do adults bleed first?
gums
kidneys
(occult!)
71
What is Disseminated Intravascular Coagulation?
acquired coagulation disorder
- caused by intravascular activation of coagulation + fibrinolytic systems (thrombin + plasmin activated)
- simultaneous hemorrhage & thrombosis
72
** DIC: patho **
THROMBIN converts FIBRINOGEN → FIBRIN
= fibrin clots in microcirculation
= ↓ coagulation factors (fibrinogen, prothrombin, plts, V, VIII)
THROMBIN activates FIBRINOLYTIC SYSTEM
= lyses FIBRIN CLOTS → FIBRIN DEGRADATION PRODUCTS (FDP)
= FDP anticoagulant activity → hemorrhage + coag factor depletion
73
What lab values are pretty diagnostic for DIC?
+ D-Dimer
↑ FDPs
predictive accuracy 96%
74
DIC: mgmt *
TREAT UNDERLYING CONDITION
- plt transfusion
- FFP (replace clotting factors)
- cryoprecipitate (maintain fibrinogen levels)
OVERALL GOALS
1. stop bleeding 2. ↑ fibrinogen + plt, 3. ↓ FDP
75
What is the point of cryoprecipitate in DIC mgmt? *
maintain those fibrogen levels - this kills the crab I mean reverses the patho of DIC
76
What is the duration of Ferrous Sulfate therapy for the treatment of iron deficiency anemia?
4 - 6 months
77
What intervention is indicated in the correction of supra therapeutic PT and PTT?
FFP
78
What electrolyte abnormalities are associated with blood transfusions
hypocalcemia
| hyperkalemia
79
Half life of warfarin (Coumadin)
36 - 42 hrs
80
20 mg IV morphine is the equivalent of __ PO morphine?
60 mg PO morphine
81
What is the most common type of anemia across all age groups?
iron deficiency
82
Why do we care about Total Iron Binding Capacity? Normal?
Transferrin is the protein that carries loose iron around in the blood. TIBC tells us if the transferrin molecules are carrying a lot of Fe or if the body has the capacity to bind more.
250 - 450 ug/dL
83
What are some examples of iron-rich foods?
```
raisins
leafy greens
red meat
citrus
iron fortified shit
```
84
Thalassemia is found mainly in which populations?
Mediterranean, African, Middle Eastern, Indian, Asian
85
Why does anyone care about folic acid?
Because it is needed to make RBCs.
86
What should you always think through when considering an anemia?
hgb & hct duh
MCV: volume of RBC
MCHC: % of an RBC that is hgb
87
What's the big fancy word for B12?
cyanocobalamin
88
What's a great analgesic combo for painful things like sickle cell crises or nephrolithiasis?
morphine + dilaudid
89
Why do joints hurt in sickle cell crises?
blocked circulation
90
sickle cell anemia: dx
↓ hgb
peripheral smear: classic distorted sickled RBCs
cellulose acetate and citrate agar gel electrophoresis confirm hgb genotype
91
What do you order to confirm diagnosis of leukemia?
bone marrow aspiration
92
What kind of cancer does not have radiation as a primary strategy?
Leukemia
93
How can you differentiate Hodgkin's from Non-Hodgkin's lymphoma?
look for Reed Sternberg cells (Hodgkin's)
lymphadenopathy has a less predictable spread in Non-Hodgkins; Hodgkins is cervical adenopathy with a predictable pattern
94
How do you stage lymphomas?
biopsy enlarged node and decide:
Stage I: single node/group
Stage II: +1 group on 1 side of diaphragm
Stage III: spleen involved, nodes on both side of diaphragm
Stage IV: liver or bone marrow involved
95
Your patient is a 29 yo male who presents with sudden weight loss and cervical adenopathy. What is an important ddx to consider? What lab is important to order?
Hodgkin's Lymphoma
- mostly males, avg age 32
- cervical adenopathy + predictable pattern
- order a lab to look for Reed Sternberg cells
96
How serious is idiopathic thrombocytopenia purpura?
eh - it can be asymptomatic for long periods and patients only occasionally develop bleeding requiring hospitalization
mgmt may not be necessary until plt less than 20000
97
ITP: mgmt
may not be necessary until platelets under 20,000
- high dose CORTICOSTEROIDS: ↑ plt w/in 2 - 3 days
- IV gamma globulin helps too
- plt transfusions = occasional benefit
98
Describe thrombocytopenic precautions *
- avoid constipation (fiber, laxatives)
- no flossing or shaving
- hold pressure 5+ minutes for cuts, line insertion, etc
99
Your patient has some thrombocytopenia going on. You have a few suspected etiologies, but how would you differentiate between idiopathic thrombocytopenia purpura from systemic lupus erythematosus? *
analyze dat bone marrow
100
fibrinogen normal *
170 - 400
101
FDP normal *
under 10 mcg/mL
40+ is considered critical
102
normal PT + PTT *
PT 11 - 14 sec
| PTT 25 - 35 sec
103
RBCs normal *
just go with 4 - 5 million/uL
104
difference between PT + PTT + aPTT *
how long does it take blood to clot?
PT: measures extrinsic system integrity
PTT: measures intrinsic system integrity
aPTT: used to monitor heparin
105
how does heparin work? what do you use to monitor its efficacy?
inhibits factors X and thrombin, while activating anti-thrombin
aPTT
106
how do you distinguish thalassemia from a GI bleed?
↓ MCV + MCHC
| microcytic, hypochromic anemia
107
what is considered high ferritin level in anemia of chronic disease? *
greater than 100 ng/mL
108
DIC think...
FDP
109
HIT tx *
direct thrombin inhibitor
argatroban
lepirudin
